Revision Total Hip Replacement

Transcription

1 Revision Total Hip Replacement Dr. (Prof.) Anil Arora MS (Ortho) DNB (Ortho) Dip SIROT (USA) FAPOA (Korea), FIGOF (Germany), FJOA (Japan) Commonwealth Fellow Joint Replacement (Royal National Orthopaedic Hospital, London, UK) Senior Knee and Hip Replacement Surgeon Associate Director Department of Orthopaedics and Joint Replacement Max Superspeciality Hospital, Patparganj, Delhi (India) anilarora@delhiorthojournal.com

2 Difficult Journey..Revision THR Planning Preparedness Prayer. previous operative notes

3 Planning Why did earlier one failed?? What implants are in. How to remove them. What bone stock will be left. Use classification system for preparedness What all Implants are needed Need for allograft. Postop Rehabilitation

4 Why the earlier one failed? Aseptic loosening / Particle disease Infection Instability Implant failure Periprosthetic fracture Any other cause

5 Plain radiograph AP Orthogonal Full Length Femur Judet Views

6 Judet s Views

7 4 parameters..acetabular EVALUATION Amount of superior migration of hip centre. Ischial osteolysis superior border of obturator foramen (Loss of bone from inferior aspect of posterior column) Teardrop Osteolysis (Loss of bone from inferior aspect of anterior column, lateral aspect of pubis and medial wall) Medial Migration relative to Kohler s line Outline your bone loss!

8 A Crucial Identification : Pelvic Discontinuity 4 key elements: Visible transverse fracture line Medial shift of hemipelvis Rotation of hemipelvis (superior relative to inferior) Obturator foramen asymmetry

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12 Bone Scan : NPV The sensitivity and negative predictive value of the indium leukocyte scan for infection are both very high, approaching 95% and 100%, respectively, Useful >>>

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15 Try to rule out Infection..Reasonably ESR Eeak 5-7 days operation, pre-operative levels in 3 months. CRP Early peak 2-3 days after surgery, normal first 3 wks after operation. IL-6 Peak - first 6 to 12 hours baseline- 3 Days A combination of CRP and IL-6 has recently been shown to provide excellent sensitivity in the assessment of infection after THR. Bottner F, Erren M, Wegner A, Winkelmann K, et al. Interleukin-6, procalcitonin and TNF alpha: markers of peri-prosthetic infection following total joint replacement. J Bone Joint Surg [Br] 2007;89-B:94-9.

16 Perioperative testing for joint infection in patients undergoing revision total hip arthroplasty. Schinsky MF, Della Valle CJ, Sporer SM, Paprosky WG. J Bone Joint Surg Am Sep;90(9): Revision THR Preop ESR < 30mm/hr & CRP < 10 mg/dl NONE infected!!!!!!!!!!!!!!!!! ESR > 30mm/hr & CRP>10mg/dL & Synovial fluid WBC count > 3000 wbc/ml Strongly correlated with periprosthetic infection

17 Implants

18 Keep set of implants with you for surgery All possible head sizes Metal rings and cages Cables Pelvic reconstruction Plates Constrained liners Allogenic bone grafts

19 Cups / Ring /Cage /

20 Keep set of implants with you for surgery

21 Allogenic bone grafts Cables Plates

22 Exposure Multiple Incision Try and Re-establish planes Identify and Isolate Sciatic Nerve

23 Exposure : Wide Exposure

24 Exposure Generous Release (Fibrous tissue may be stronger than thin Papery Bone) Excise Pseudocapsule and metal laiden tissue if any Careful Dislocation

25 Sequence of Removal Femoral Stem (Head in Uncemented) Acetabulam Cement Debridement

26 Cemented Acetabular Removal

27 Uncemented Acetabular Removal

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32 Femoral Implant Removal

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36 Don t Hesitate to Perform ETO

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38 ETO Advantages Enhancement of cemented and cementless femoral component removal. Exposure of the femoral diaphysis for bone grafting femoral deficiencies. Increased exposure of the acetabulum Correction of femoral deformities such as varus remolding. Improved soft-tissue tensioning of the trochanter and abductor mechanism. Increased trochanteric union rate. Decreased operative time.

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40 Cement Removal Set

41 Equipment Flexible thin osteotomes for cementless stem removal Image Intensifier Flexible Medullary Reamers Fiberoptic lighting

42 High Speed Pneumatic Drills and Burr

43 Orthosonics System for Cemented Arthroplasty Revision (OSCAR)

44 Acetabular Reconstruction

45 Paprosky Classification of Acetabular Bone Loss Severity of Bone Loss and Ability of remaining host bone To provide INITIAL STABILITY to Cementless Acetabular Cup till bony ingrowth occurs.

46 Paprosky Classification of Acetabular Bone Loss

47 Type 1 - Minimal deformity, Intact Rim Rim is intact and supportive without distortion Focal areas of contained bone loss Hemispherical cementless implant is almost completely supported by native bone and has full inherent stability No migration of the component

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49 Type 2 (A,B,C) Acetabulum is distorted. At least 50% host bone contacting the surface area of the component. Anterior and posterior columns remain intact May elevate hip centre to 1.5 cm to achieve stability. Xray: Superior migration of the hip center is <3 cm No significant osteolysis, Ischium or Teardrop

50 Type 2 A- Intact superior rim with Superomedial bone Lysis Defect is contained Superior medial

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53 Type 2 B Absent Superior Rim Superolateral Migration Superior rim is deficient for <1/3 Circumference Columns are supportive for a hemispherical cementless implant Defect is lateral Segmental defect

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55 Type 2 C- Intact Rim Localized destruction of medial wall Migration of the acetabular component medial to Kohler line Medial wall defect Rim will support a hemispherical component

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58 Type 3 : More than 1/3 rim missing! Superior Migration >3 cm The remaining acetabular rim will not provide adequate initial stability for the component to achieve reliable biologic fixation. Structural allograft or highly porous metal augments are required to restore the center of rotation to the proper anatomic location and provide mechanical stability to the implant.

59 Type 3 A- Rim loss from clock, Supero-Lateral cup migration Defect involves >1/3 but not more than 1/2 the circumference (10.0 clock clock ) Migration >3 cm above the obturator line Ischial lysis <15 mm inferior to the obturator line Partial destruction of the teardrop. Component will be at or lateral to Kohler line and the ilioischial and iliopubic lines will be intact. Up and Out!

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63 Type 3B - Bone loss from clock around rim, Supero-Medial cup migration Rim defect is >1/2 the circumference (9-5.0 clock) High risk for occult pelvic discontinuity < 40% host bone. No inherent stability achievable with a trial implant >3 cm of superior migration to the obturator line Complete destruction of the teardrop More extensive ischial osteolysis (>15 m below the superior obturator line) Migration medial to Kohler line Up and In!

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68 Cages Lateralize the hip center Often lie quite vertical. Often lie in a Retroverted position.so cement the Cup In Appropriate Position

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71 Pelvic Discontinuity

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75 Other Options

76 IMPACTION GRAFTING Benefits Fills big defects Osteoconductive properties Moderate support features Disadvantages Poor osseointegration Lysis of the bone graft High risk of infection The greater the extent of the coverage of the acetabular component by the graft, the greater the rate of late failure [Shinar AA, Harris WH. J Bone Joint Surg Am Feb;79(2):159-68] total survival rate of 87.5%, anti-protrusio cages and structural allografts [Regis D. et al. J Arthroplasty Sep;23(6):826-32]

77 IMPACTION GRAFTING INTRAOP LOOSE CUP IMPACTION GRAFTING POSTOP XRAY AFTER 2 YEARS INTRAOP PAP 3 AFTER CUP REMOVAL

78 Constrained Acetabular Insert Primary and revision patients at high risk of hip dislocation due to History of prior dislocation, Bone loss Joint or soft tissue laxity Neuromuscular disease Intraoperative instability YES Bone or musculature compromised by disease, infection or prior implantation, which cannot provide adequate support or fixation for the prosthesis. Infection in or about the hip joint. NO Skeletal immaturity.

79 Paprosky Classification of Femoral Bone Loss

80 Based on three variables a) The location of bone loss (metaphyseal vs. diaphyseal) b) The degree of remaining support of the proximal femur (degree of cancellous bone loss) a) The amount of isthmus remaining for diaphyseal fixation.

81 Type I- Minimal Metaphyseal bone loss

82 Type II- Extensive Metaphyseal bone loss with Intact Diaphysis

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86 Type III A Extensive Meta- Diaphyseal bone loss Minimum of 4 cm of intact cortical bone in the diaphysis

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90 Type III B Extensive Meta- Diaphyseal bone loss Less than 4 cm of intact cortical bone in the diaphysis

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93 Type IV Extensive Meta-diaphyseal bone loss NONSUPPORTIVE diaphysis

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98 Other Options

99 Cement in cement

100 77 Yr

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104 72 YR

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106 APC Femur A reliable way to reconstruct in difficult scenario.

107 APC Acetabulum INTRAOP PREOP APC 8 YRS POSTOP INTRAOP

108 Preparedness Be ready for all sorts of possible complications Massive bone defects Fracture / Cortical perforation Incomplete removal of implants/hardware Inability to achieve solid fixation Neurovascular injury Iatrogenic pelvic discontinuity

109 Message Need to learn Tips and Tricks Always keep Bail out implants and adequate amount of allograft. Shall have done about 100 hips Assist as many revisions as you can (at least twenty) before venturing.

110 THANK YOU